Abdominal Examination

Abdominal ExaminationAbdominal Examination

H.A.Soleimani MDH.A.Soleimani MD

Gastroenterologist Gastroenterologist

Adapted by Judy Gearhart, MDAdapted by Judy Gearhart, MD

Gastrointestinal HistoryGastrointestinal History

www.rightdiagnosis.com

Be a detective!Be a detective!

Think about what all could cause this Think about what all could cause this presentation.presentation.

What are risk factors?What are risk factors?

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How to perform the physical How to perform the physical examination?examination?

Exposing only the Exposing only the area that are being area that are being examined examined

Offer a chaperone for Offer a chaperone for both sexes.both sexes.

Explain what you're Explain what you're going to dogoing to do

Sequential Sequential

Important aspects of physical Important aspects of physical examinationexamination

The examiner should The examiner should continue speaking to continue speaking to the patientthe patient

Showing care to his Showing care to his disease and answer to disease and answer to patient’s questionspatient’s questions

Gloves should be worn when..Gloves should be worn when..

Examining any Examining any individual with individual with exudative lesionsexudative lesions or or weeping dermatitisweeping dermatitis

When handling When handling blood-soiledblood-soiled or or body body fluid-soiledfluid-soiled sheets sheets or clothingor clothing

General principles of examGeneral principles of exam

Have the patient Have the patient empty their bladder empty their bladder before examinationbefore examination

Have the patient lie in Have the patient lie in a comfortable, flat, a comfortable, flat, supine positionsupine position

Have them keep their Have them keep their arms at their sides or arms at their sides or folded on the chest folded on the chest


Before the exam, ask Before the exam, ask the patient to the patient to identify identify painful areaspainful areas so that so that you can examine you can examine those areas lastthose areas last

During the exam pay During the exam pay attention to their attention to their facial facial expressionexpression to assess to assess for sign of discomfort for sign of discomfort


Use Use warm handwarm hand, , warm stethoscopewarm stethoscope, , and have and have short finger short finger nails nails

Approach the patient Approach the patient slowlyslowly and and deliberately deliberately explaining explaining what you what you will be doing will be doing


Stand right side of the Stand right side of the bed (tradition-depends on bed (tradition-depends on patient, room, and patient, room, and situation)situation)

Exam with right hand Exam with right hand (again, it depends)(again, it depends)

Head just a little Head just a little elevated elevated

Ask the patient to keep Ask the patient to keep the the mouth partiallymouth partially open open and breathe gentlyand breathe gently


If muscles remain If muscles remain tensetense, patient may , patient may be asked to be asked to rest rest feetfeet on table with on table with hipships and and knees knees flexedflexed

Other helpful points on examinationOther helpful points on examination

Take a Take a spare bed spare bed sheetsheet and drape it and drape it over their lower body over their lower body such that it just such that it just covers the upper covers the upper edge of their edge of their underwear underwear


If the patient is If the patient is ticklish ticklish or frightened,or frightened,initially use the initially use the patient’s patient’s hand under hand under yoursyours as you palpate as you palpate When patient When patient calms calms then use your hands then use your hands to palpate. to palpate. Watch the Watch the patient’s patient’s faceface for discomfort. for discomfort.

Think AnatomicallyThink Anatomically

When looking, When looking, listening, feeling and listening, feeling and percussing, percussing, imagine imagine what organs livewhat organs live in in the area that you are the area that you are examining. examining.

Right Upper Quadrant (RUQ)Right Upper Quadrant (RUQ)

liver, liver, gallbladdergallbladder, , duodenum, duodenum, right kidney right kidney and hepatic and hepatic flexure of colonflexure of colon

Right Lower Quadrant (RLQ)Right Lower Quadrant (RLQ)

Cecum, Cecum, appendix (in appendix (in case of female, case of female, right ovary & right ovary & tube)tube)

Left Lower Quadrant (LLQ)Left Lower Quadrant (LLQ)

Sigmoid Sigmoid colon (in case colon (in case of female, left of female, left ovary & tube)ovary & tube)

Left Upper Quadrant (LUQ)Left Upper Quadrant (LUQ)

Stomach, Stomach, spleen, left spleen, left kidney, pancreas kidney, pancreas (tail), splenic (tail), splenic flexure of colonflexure of colon

Epigastric AreaEpigastric Area

Stomach, Stomach, pancreas pancreas (head and (head and body), aortabody), aorta

Landmarks of the abdominal wall,

Costal margin, umbilicus, iliac crest, anterior superior iliac spine, symphysis pubis, pubic tubercle, inguinal ligament, rectus abdominis muscle, xiphoid process.

Physical Examination of the Physical Examination of the AbdomenAbdomen

InspectionInspection Auscultation Auscultation Percussion Percussion Palpation Palpation Special Tests Special Tests

Appearance of the abdomenAppearance of the abdomen

Is Aortic Is Aortic pulsationpulsation? ?

Is it flat or Is it flat or Scaphoid Scaphoid ((Normally)?Normally)?

DistendedDistended? ?

If enlarged, does this If enlarged, does this appear appear symmetricsymmetric??

With With bulging or bulging or movingmoving??


Global Global abdominal abdominal enlargement is enlargement is usually caused usually caused by by airair, , fluidfluid, or , or fatfat..


Localized Localized enlargement, enlargement, probably distended probably distended GB space GB space occupyingoccupying lesion, lesion, hepatomegaly….hepatomegaly….

An aortic aneurysmAn aortic aneurysm

Palpable massPalpable mass

Patient feeling of Patient feeling of pulsationpulsation

On rare occasions, a On rare occasions, a lump can be visible. lump can be visible.

Appearance of the abdomenAppearance of the abdomen((Skin)Skin)

Abnormal Abnormal venousvenous patternspatterns

Abnormal Abnormal discolorationdiscoloration

Umbilicus isUmbilicus is sunkensunken

StriaeStriae

Stretch marks are a Stretch marks are a light silver hue.light silver hue.

Pregnant and obese Pregnant and obese individualsindividuals

Cushing’s syndrome Cushing’s syndrome (more purple or pink).(more purple or pink).

Appearance of the abdomenAppearance of the abdomen ( (Skin)Skin)

TattoosTattoos

Scars

Cullen’s signCullen’s sign

Ecchymosis, Ecchymosis, periumbilicalperiumbilical. . (intraperitoneal (intraperitoneal hemorrhage hemorrhage ruptured ectopic ruptured ectopic pregnancy, pregnancy, hemorrhagic hemorrhagic pancreatitis..)pancreatitis..)

Grey-Turner’s signGrey-Turner’s sign

Ecchymosis of Ecchymosis of flanks. flanks. ((retroperitoneal retroperitoneal hemorrhage hemorrhage such as such as hemorrhagic hemorrhagic pancreatitis) pancreatitis)

Upward flow direction indicates IVC obstruction

Outward flow pattern from umbilicus in all directions ? Portal HTN


Areas which Areas which become more become more pronounced when pronounced when the patient the patient valsalvasvalsalvas are are often associated often associated with with ventral ventral herniashernias

Visible PulsationsVisible Pulsations

More conspicuous in the More conspicuous in the thin than in the fatthin than in the fat

Greater in the old than in Greater in the old than in the young.the young.

Increased in Increased in thyrotoxicosis, thyrotoxicosis, hypertension, or aortic hypertension, or aortic regurgitation)regurgitation)

In those with an aortic In those with an aortic aneurysm and tortuous aneurysm and tortuous aortaaorta

In those who have a In those who have a mass joining the aorta to mass joining the aorta to the anterior abdominal the anterior abdominal wall. wall.

Visible gastric PeristalsisVisible gastric Peristalsis

Gastric peristalsis is Gastric peristalsis is commonly seen in commonly seen in neonates with neonates with congenital congenital hypertrophic pyloric hypertrophic pyloric stenosisstenosis

Intestinal peristalsis in Intestinal peristalsis in partial and chronic partial and chronic intestinal obstructionintestinal obstruction

Colonic obstruction is Colonic obstruction is usually not manifest usually not manifest as visible peristalsis as visible peristalsis

Visible intestinal Visible intestinal PeristalsisPeristalsis

Appearance of the abdomenAppearance of the abdomen Patient's movement Patient's movement

Patients with Patients with kidney kidney stonesstones will frequently will frequently writhe on the writhe on the examination table, examination table,

unableunable to find a to find a

comfortablecomfortable positionposition

Appearance of the abdomenAppearance of the abdomen Patient's movement Patient's movement

Patients with Patients with peritonitisperitonitis prefer to lie prefer to lie

very stillvery still as any as any motion causes further motion causes further peritoneal irritation peritoneal irritation and pain. and pain.

AuscultationAuscultation

Abdominal examinationAbdominal examination

Auscultation for bowel soundsAuscultation for bowel sounds

It is performed It is performed before before percussion or percussion or palpationpalpation


Normal sounds are Normal sounds are

due to due to peristaltic peristaltic activityactivity..Peristalsis: A Peristalsis: A pregressive pregressive wavelike wavelike movementmovement that occurs that occurs involuntarily in hollow involuntarily in hollow tubes of the body. tubes of the body.

AuscultationAuscultation

Listening for 15-60 Listening for 15-60 secondssecondsBowel sounds Bowel sounds cannot cannot be said to be absentbe said to be absent unless they are not unless they are not heard after listening heard after listening for for 3-5 minutes3-5 minutes. .

Three things about bowel Three things about bowel soundsound

Are bowel sounds Are bowel sounds present?present?

If present, are they If present, are they frequent or sparse frequent or sparse (i.e.quantity)? (i.e.quantity)?

What is the nature of What is the nature of the sounds the sounds (i.e.quality)? (i.e.quality)?

Bowel sound decreaseBowel sound decrease

Inflammatory Inflammatory processesprocesses of the of the serosaserosa

After abdominal After abdominal surgery surgery

In response to narcotic In response to narcotic analgesics or analgesics or anesthesia. anesthesia.

Bowel Sounds IncreaseBowel Sounds Increase

Inflammation of the Inflammation of the intestinal mucosaintestinal mucosa will cause will cause hyperactivehyperactive bowel bowel sounds. sounds.


Processes which Processes which lead to lead to intestinal intestinal obstructionobstruction initially initially cause frequent cause frequent bowel sounds, bowel sounds, referred to as referred to as "rushes.""rushes."


““Rushes" means Rushes" means as the intestines as the intestines trying to trying to force force their contentstheir contents through a through a tight tight opening.opening.

Auscultation for bowel Auscultation for bowel soundssounds

““Rushes" is followed Rushes" is followed by by decreased sounddecreased sound, , called "called "tinklestinkles," and ," and then silence. then silence.

BruitsBruits

Bruits Bruits confined confined to systoleto systole do not do not necessarily necessarily indicate diseaseindicate disease. .

Auscultation for Auscultation for vascular sounds vascular sounds

(bruits)(bruits)

AorticAortic (midline between (midline between umbilicus and xiphoidumbilicus and xiphoid

RenalRenal ( (two inches two inches superiorsuperior to and to and two two inches lateral toinches lateral to umbilicus)umbilicus)

Common iliac (Common iliac (midway midway between umbilicus between umbilicus and midpoint of and midpoint of inguinal ligamentinguinal ligament))

Auscultation for vascular sounds Auscultation for vascular sounds (bruits)(bruits)

Presence of a Presence of a bruit bruit on the renal arteryon the renal artery would lend would lend supporting supporting evidence for the evidence for the existence of existence of renal renal artery stenosisartery stenosis. .

PercussionPercussion


Percussion SoundsPercussion Sounds

Resonance (heard over lung tissue)Resonance (heard over lung tissue)

Tympany (heard over most of abdomen)Tympany (heard over most of abdomen)

Dullness (heard over solid organs)Dullness (heard over solid organs)

Flatness (heard over muscle)Flatness (heard over muscle)

Percussion (technique)Percussion (technique)

DIP joint of third DIP joint of third fingerfinger (pleximeter) (pleximeter) pressed firmly on the pressed firmly on the abdomen abdomen remainder remainder of hand not touching of hand not touching the abdomenthe abdomen

Same technique as for lungsSame technique as for lungs


Striking hand Striking hand should move should move only at the only at the wristwrist, , with only little with only little more than more than force force of gravityof gravity


Middle fingerMiddle finger of of striking hand striking hand (plexor) should (plexor) should knock the knock the pleximeter firmly, pleximeter firmly, with a with a strong strong notenote

There are two basic sounds with There are two basic sounds with PercussionPercussion

TympaniticTympanitic (drum-like) (drum-like) sounds sounds produced by produced by percussing over percussing over air filled air filled structuresstructures. .

There are two basic sounds with There are two basic sounds with PercussionPercussion

Dull soundsDull sounds that that occur when a occur when a solid solid structurestructure (e.g. liver) (e.g. liver) or or fluid fluid (e.g. ascites) (e.g. ascites) lies beneath the lies beneath the region being region being examined. examined.

Examination of Liver (Percussion)Examination of Liver (Percussion)

MidclavicularMidclavicular line line is notedis noted

Second Second intercostalintercostal space space is notedis noted

Two solid organs are percussable in the normal patient

Liver:

Covered by the ribs. Edge may protrude

1-2 centimeter below the costal margin.

Spleen:

smaller and protected by the ribs.

To determine the size of the liverTo determine the size of the liver

PercussPercuss

hepatic dullness from hepatic dullness from above (lung) and above (lung) and below (bowel).below (bowel).

Normal liver span = Normal liver span =

6 to 12 cm6 to 12 cm in the in the midclavicular line.midclavicular line.


Start just below the Start just below the right breastright breast in a line in a line with the middle of with the middle of the clavicle. the clavicle.

Percussion here Percussion here should produce a should produce a resonantresonant note. note.


As you move As you move your hand down your hand down you will percuss you will percuss over the liver, over the liver, which will which will produce a duller produce a duller sound. sound.


Continue Continue downwarddownward until until the sound the sound changes once changes once again. again.

This is the This is the inferior inferior margin of the margin of the liver.liver.

Examination of Liver (Percussion)Examination of Liver (Percussion)

Upper margin is Upper margin is noted by noted by first dull first dull percussionpercussion note note

Lower margin is Lower margin is noted by noted by first first tympanitictympanitic note note

Examination of SpleenExamination of Spleen(Percussion)(Percussion)

Percussion at Castell’s SpotPercussion at Castell’s Spot

Castell’s Spot identifiedCastell’s Spot identified

Left anterior axillary line identifiedLeft anterior axillary line identified

Left lower costal margin identifiedLeft lower costal margin identified

Percussion at Castell’s Spot while patient Percussion at Castell’s Spot while patient inhales and exhales deeplyinhales and exhales deeply

Dull tone indicates Dull tone indicates possible possible splenomegalysplenomegaly

Spleen percussionSpleen percussion

Enlarged spleen: Enlarged spleen: produces a produces a dull dull tonetone, in the , in the LUQLUQ

Palpation Palpation


Abdominal Palpation Abdominal Palpation

Technique Technique

Light Light

Deep Deep

Liver edge Liver edge

Spleen tip Spleen tip

Kidneys Kidneys

Aorta Aorta

MassesMasses

Abdominal palpationAbdominal palpation

To palpate four To palpate four quadrantsquadrants superficially superficially from LLQ from LLQ counterclockwisecounterclockwise

Light PalpationLight Palpation

Light PalpationLight Palpation

First First warm your warm your handshands by rubbing by rubbing them together before them together before placing them on the placing them on the patient.patient.

Abdominal wall Abdominal wall depressed depressed approximately 1 cmapproximately 1 cm

Palpation (light)

Any areas of pain or tenderness are reserved for evaluation at the end of the exam

Palpation Light palpation assesses

Tenderness Tenderness (muscle (muscle splinting, wide eyes, splinting, wide eyes, moaning, teeth moaning, teeth grittinggritting).).

Muscle tone, Cutaneous hypersensitivity (suggests peritoneal irritation)

Palpation Light palpation assesses

Superficial mass (intramural): more prominent with head raised

Intra-abdominal mass: less prominent with head raised

Deep PalpationDeep Palpation

Deep PalpationDeep PalpationUse palmar surface of fingers

Deep, firm, gentle maneuver

Use finger Use finger padspads (do (do not not “dig in” with finger “dig in” with finger tipstips))

Deep PalpationDeep Palpation

Palpate tender areas Palpate tender areas lastlast

Try to identify Try to identify abdominal abdominal massesmasses or or areas of areas of deep deep tendernesstenderness

Two handed technique

When deep When deep palpation is palpation is difficult, examiner difficult, examiner may want to use may want to use left hand placed left hand placed over right handover right hand to to help exert pressurehelp exert pressure

Normal structures that may be Normal structures that may be palpablepalpable

Sigmoid colon Sigmoid colon

LiverLiver

KidneyKidney

Abdominal aortaAbdominal aorta

Iliac arteryIliac artery

Distended bladderDistended bladder

Gravid and non-Gravid and non-gravid uterus gravid uterus

Xyphoid processXyphoid process

spleen spleen

Abdominal massAbdominal mass

Intra abdominal Intra abdominal masses or enlarged masses or enlarged liver, gallbladder or liver, gallbladder or spleenspleen

Abdominal wall massAbdominal wall mass

Intra abdominal masses or enlargements of Intra abdominal masses or enlargements of the liver, gallbladder or spleenthe liver, gallbladder or spleen

will will shift downshift down with with inspiration and inspiration and backback with with expiration.expiration.

(not true of masses (not true of masses within the within the abdominal abdominal wallwall or or retroperitoneal retroperitoneal structuresstructures).).

Abdominal pain and Abdominal pain and Tenderness:Tenderness:

Visceral Visceral SomaticSomatic

Visceral painVisceral pain

Pain from an Pain from an organic organic lesion or functional lesion or functional disturbance within an disturbance within an abdominalabdominal viscus viscus ((dulldull, , poorly localizedpoorly localized, , and and difficultdifficult for the for the patient to patient to characterizecharacterize).).

Somatic painSomatic pain

Painful lesion of the Painful lesion of the skinskinSharp, bright, and Sharp, bright, and well localizedwell localized Indicates Indicates involvement of involvement of parietal peritoneumparietal peritoneum or the or the abdominal abdominal wall itselfwall itself

Abdominal muscle spasmAbdominal muscle spasm

Voluntary guardingVoluntary guarding Tensing abdominal Tensing abdominal muscles due to muscles due to patient anxiety, patient anxiety, ticklishness, or ticklishness, or toprevent palpation to toprevent palpation to a painful area a painful area

Involuntary guardingInvoluntary guarding Muscular spasm or Muscular spasm or rigidity due to rigidity due to peritoneal peritoneal inflammationinflammationMay be localized May be localized (early appendicitis )or (early appendicitis )or diffuse (perforated diffuse (perforated bowel) bowel)

Board-like rigidityBoard-like rigidity

Abdominal wall is Abdominal wall is tense, even as tense, even as rigid rigid as a board.as a board.

Caused by the spasm Caused by the spasm of abdominal muscle of abdominal muscle due to peritoneal due to peritoneal irritation.irritation.

Palpation of Liver, Spleen, Palpation of Liver, Spleen, and Aortaand Aorta

Liver palpation Liver palpation ((Standard Method)Standard Method)

Start in the Start in the RUQ,10 RUQ,10 centimeterscentimeters below the below the rib marginrib margin in the mid- in the mid-clavicular line clavicular line

Place Place left hand left hand posteriorlyposteriorly parallel to parallel to and supporting 11th & and supporting 11th & 12th ribs on right. 12th ribs on right.

Standard Method Liver palpationStandard Method Liver palpation

Ask the patient to Ask the patient to take a take a deep breath.deep breath.

You may feel the You may feel the edge of the liver press edge of the liver press against your fingers. against your fingers.


Palpating hand is Palpating hand is held steadyheld steady while while

patient inhalespatient inhales


Palpating hand is Palpating hand is lifted and movedlifted and moved while the patient while the patient

breathes outbreathes out

Alternate Method Liver palpationAlternate Method Liver palpation

Stand by the patient's Stand by the patient's chest.chest.

"Hook""Hook" your fingers your fingers just below the costal just below the costal margin and press margin and press firmly. firmly.

Hepatojugular reflux Hepatojugular reflux signsign

If you press the liver, If you press the liver, you will find the you will find the dilated jugular vein dilated jugular vein becomes more becomes more bulged or distended, bulged or distended, as from the as from the enlargement of liver enlargement of liver passive congestionpassive congestion resulted from resulted from right right failurefailure..

Spleen palpation Spleen palpation

Support Support lower left rib lower left rib cagecage with left hand with left hand while patient is supine while patient is supine and and lift anteriorly on lift anteriorly on the rib cagethe rib cage. .

Spleen palpation Spleen palpation

Palpate Palpate upwards upwards toward spleentoward spleen with with finger tips of right finger tips of right hand, starting below hand, starting below left costal margin. left costal margin.

Have the Have the patient take patient take a deep breatha deep breath. .

SeldomSeldom palpable in palpable in normal adults.normal adults.

Palpation of Aorta

Press down Press down deeply in deeply in the midlinethe midline above the above the umbilicus with flat umbilicus with flat palm. palm.

The aortic pulsation is The aortic pulsation is easily felt on easily felt on most most individuals. individuals.

Examination of Aorta

Hands then oriented vertically on either side of midline with distal fingers at level of pulsation; equal pressure applied until pulsation is palpated

A well defined, pulsatile mass, A well defined, pulsatile mass, greater than 3 greater than 3 cmcm across, suggests an aortic aneurysm. across, suggests an aortic aneurysm.

Special examSpecial examMurphy’s Sign Murphy’s Sign McBurney’s McBurney’s PointPointRovsing’s SignRovsing’s SignPsoas SignPsoas SignObturator Obturator SignSign

Re bound Re bound TendernessTenderness

Costovertebral Costovertebral tendernesstenderness

Shifting Shifting DullnessDullness

Fluid waveFluid wave

Murphy’s Sign (acute cholecystitis)Murphy’s Sign (acute cholecystitis)

Examiner’s hand is at Examiner’s hand is at middle inferior border middle inferior border of liver.of liver.Patient is asked to Patient is asked to take take deep inspirationdeep inspiration..If positive patient will If positive patient will experience painexperience pain and and will will stop shortstop short of full of full inspirationinspiration

Hepatitis, Hepatitis, subdiaphragmaticsubdiaphragmatic abscess Cholecystitisabscess Cholecystitis

McBurney’s PointMcBurney’s Point

Localized tenderness Localized tenderness Just below Just below midpoint midpoint of line between of line between right right anterior iliac crestanterior iliac crest and and umbilicusumbilicus..

Heel strikeHeel strike, , riding riding over bumpsover bumps in road in road while while drivingdriving,, coughingcoughing, will , will produce pain.produce pain.

McBurney’s Point (McBurney’s Point (Common CausesCommon Causes))

Appendicitis Incarcerated or Incarcerated or strangulated hernia strangulated hernia Ovarian torsion (twisted Ovarian torsion (twisted Fallopian tube) Fallopian tube) Pelvic inflammatory disease Abdominal abscess Hepatitis Diverticular disease Diverticular disease Meckel''s diverticulumMeckel''s diverticulum

Rovsing’s SignRovsing’s Sign

Patient will Patient will experience right lower experience right lower quadrant pain (in quadrant pain (in region of McBurney’s region of McBurney’s Point) when left lower Point) when left lower quadrant is palpated. quadrant is palpated.

Non-Classical AppendicitisNon-Classical Appendicitis

Iliopsoas SignIliopsoas Sign

Obturator SignObturator Sign


Patient lies on side, extends leg at the hip Patient lies on side, extends leg at the hip

oror lies on back, flexes hip against resistance lies on back, flexes hip against resistance

of examiner’s hand on thigh. of examiner’s hand on thigh.

Inflamed retrocecal appendixInflamed retrocecal appendix pain pain


Anatomic basis for Anatomic basis for the psoas sign: the psoas sign: inflamed appendix is inflamed appendix is in a retroperitoneal in a retroperitoneal location in contact location in contact with the psoas with the psoas muscle, which is muscle, which is stretched by this stretched by this maneuver. maneuver.


Internally rotate right leg at the hip with the knee Internally rotate right leg at the hip with the knee at 90 degrees of flexion. Will produce pain if at 90 degrees of flexion. Will produce pain if inflamed appendix is in pelvis. inflamed appendix is in pelvis.


Anatomic basis for Anatomic basis for the obturator sign: the obturator sign: inflamed appendix in inflamed appendix in the pelvis is in contact the pelvis is in contact with the obturator with the obturator internus muscle, internus muscle, which is stretched by which is stretched by this maneuver. this maneuver.

Rebound TendernessRebound Tenderness ((FFor peritoneal irritation)or peritoneal irritation)

WarnWarn the patient what the patient what you are you are about to doabout to do. .

Press deeplyPress deeply on the on the abdomen with your hand. abdomen with your hand.

After a moment, After a moment, quickly quickly release pressurerelease pressure. .

If it If it hurts more when you hurts more when you release,release, the patient has the patient has rebound tenderness. [rebound tenderness. [4] ]

Costovertebral TendernessCostovertebral Tenderness (Often with renal disease)(Often with renal disease)

Use the Use the heel of your heel of your closed fistclosed fist to strike to strike the patient firmly the patient firmly over the over the costovertebral costovertebral angles. angles.

CompareCompare the the left left and right sides. and right sides.

Examination for Shifting Dullness

Patient rolled slightly toward the examined side; movement of the dull point medially is described as “shifting dullness” and suggests ascites

Fluid waveFluid wave

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Abdominal Examination